Many health systems face aging infrastructure and frequently question whether it’s time to consider a replacement facility or make improvements to on-campus facilities, including expansion projects or renovations over time.

The first option is capital intensive in the short term and should provide value over many years to come. The second option can offer a more financially feasible near-term solution but requires creativity to provide lasting value.

As healthcare providers plot their path forward, they need to consider system-wide strategic thinking, which is critical to optimize the value of capital investments to determine the long-term role each facility will play within the broader continuum of care. As providers are being asked to take on more accountability and financial risk for cost and outcomes under value-based contracts, they will increasingly need to address the whole continuum of care, as population health initiatives require a comprehensive approach to improving care coordination and management of chronic illness outside of the hospital.

Older facilities may pose challenges to reach the Institute for Healthcare Improvement’s Triple Aim goals, which include improving health outcomes of communities served, bettering access to care and the overall patient experience, and reducing the per capita cost of care.

Optimizing the health of communities where population centers and community demographics have shifted over time can pose questions related to services provided at individual sites of care such as developing urgent care centers in disadvantaged communities to improve access to health services or free-standing emergency centers in newly developed extended markets. This is especially the case where older hospital campuses no longer provide convenient primary care and routine outpatient services as they were designed during a period of time focused solely on inpatient care.

The shift toward greater community-based care and home care is putting pressure on older facilities as they respond to an increased acuity level and intensity of remaining services. In many cases, existing facilities can be repositioned over time to meet future acute care service needs if the existing infrastructure can support higher intensity service delivery, while new care sites are developed to provide lower-cost settings for routine outpatient care.

Replacement strategies, that include relocation to a new site of care, may provide a better value proposition for aging facilities that struggle to meet basic requirements for contemporary care delivery and facility quality metrics that include:

  • A focus on patient experience, ease of wayfinding, and convenient access to services
  • Complying with current Facility Guidelines Institute guideline standards
  • Providing point of care clinical support services
  • Adequate floor to floor heights to accommodate contemporary infrastructure, including HVAC.

Deciding whether to renovate and or expand existing assets versus considering a new site and facility poses difficult questions for an organization. Of greatest importance is the organization’s ability to fund a large-scale development project within a five-year time frame versus repositioning an existing aging facility over a five- to 15-year time horizon. It can be a relatively straightforward decision based upon limited near-term capital resources, although the longer view may suggest that solution is merely a quick fix.

If the available site area is limited to support phased redevelopment on campus, or the value of existing assets does not warrant the continued allocation of capital dollars, then a complete replacement facility can become the most viable option.

As an example, Adventist HealthCare Washington Adventist Hospital relocated within its previous service area from Takoma Park, Md., to the White Oak section of Montgomery County. The new 472,947-square-foot acute care and medical campus continues Washington Adventist Hospital’s 109-year legacy of providing healthcare to the community.

The new hospital, designed for improved clinical efficiency, features 170 all-private beds and an emergency department planned to accommodate 50,000 to 60,000 visits per year. In addition, an ambulatory care center with outpatient and cancer treatment services is attached to the hospital and also houses physician offices and space for outpatient programs.

The new campus allows Washington Adventist Hospital to provide the best comprehensive care in an environment that celebrates health, community, and nature. Light-filled public spaces, roof gardens, courtyards, a dining terrace, and walking trails promote a restorative healing environment for patients, family, and staff. The architectural design is influenced by Washington Adventist Hospital’s faith-based mission and is inspired by the natural features of the site, with the wood-like façade designed to evoke the dappled rhythm of a woodland setting.

Determining the best path forward for an individual hospital campus requires understanding the health system’s approach to routine and subspecialty clinical service delivery to maximize access, quality, and perceived value. As health systems mature, decisions regarding the type and quantity of inpatient beds provided at individual hospitals will become more system-based.

A perfect example is the consolidation of maternity services. Depending upon travel distances to regional hospital campuses, OB services have been quick to consolidate to a single campus for efficiency. The same can be said for sub-specialty surgical services, with consolidation to a single facility to optimize the quality-of-care delivery.

To help decide “what goes where,” facility functional and operational assessments, aligned with strategic service line planning, will play a more significant role in defining the true value of existing assets.

Triple Aim goals of improving outcomes, costs, and care experience are directly related to improving patient engagement, connected care delivery, and ultimately, patient satisfaction. It is essential to understand how each facility type responds to the needs of a diverse patient and visitor population.

Environments need to be responsive to the special needs of the elderly, patients who expect expedited outpatient care or testing, patients who require connected care among a variety of sub-specialties, patients who frequent the facility for multiple treatments or chronic illness, patients who receive treatments of long duration, and patients who receive targeted or personalized services.

Ray Brower is principal at CallisonRTKL. He is based in Rockville, Md., and can be reached at